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Reflections on the Committee on Infectious Diseases
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The Committee on Infectious Diseases of the American Academy of Pediatrics is responsible for developing guidelines on infectious disease and immunization issues for the AAP. Once approved by the AAP Board of Directors, these guidelines become AAP policy. In addition, every 3 years the COID prepares an updated edition of the Red Book: Report of the Committee on Infectious Diseases, which incorporates all of the AAP policies. The Red Book has evolved significantly since it was first published in 1938. What started out as an eight-page manual with 18 chapters has evolved into a 984-page resource trusted by thousands of American pediatricians and other health care professionals.
As vaccines and antimicrobial therapies have improved, there have become greater opportunities to provide guidance on how to best use these available therapeutic modalities. Here, we present a special interview with some past and present members of the AAP’s Committee on Infectious Diseases and share their thoughts on how the field of infectious diseases has changed since the committee was first formed.
Our panel members include Michael T. Brady, MD, who is the current chair of the AAP COID, and Infectious Diseases in Children Editorial Board members Larry K. Pickering, MD, and Caroline B. Hall, MD. All of the panel members said it is considered a privilege to serve on the AAP COID because there is no other committee that is as highly influential in children’s health.
What years did you serve on the Committee on Infectious Diseases (COID)?
Pickering: I was a member of COID from 1990 through 1996 at which time I became associate editor of the Red Book for two editions under the leadership of Georges Peter, MD. I was editor of the 2000 edition of the Red Book and have been editor of the Red Book for a total of five editions, including the 2012 version that will be published in June.
Brady: I was a member of the COID from July 2005 until June 2010. I have served as chair since July 2010. My term as chair ends in June 2014.
Hall: I have had the fortune to be involved with the COID and the production of the Red Book over a period of more than two decades that brought many innovations and exciting changes. I first became a member of the COID in 1984 and was Chair of the COID from 1991 to 1995.
What were the top three most controversial issues that came before the COID during your tenure? How were they resolved?
Pickering: In the past few years, there has been a major increase in the number and complexity of vaccine recommendations, some of which have been controversial, including recommendations for use of the human papillomavirus vaccine for males and a second dose of meningococcal vaccine for adolescents, which was recommended because of decline of measured immunity following just one dose at 11 to 12 years of age.
There has always been controversy over the best means to deliver therapy for prevention of respiratory syncytial virus (RSV). COID recommendations are evidence-based, but sometimes there is disagreement with COID recommendations, which presents a challenge.
Brady: I agree with Larry about the controversy over RSV treatment. Modification of the guidelines for the use of palivizumab (Synagis, MedImmune) in infants who were born with a gestational age of 32 to 36 weeks has been very controversial. Palivizumab is an extremely expensive preventive strategy. The number of children in the 32- to 36-week gestation age group is between 200,000 and 250,000. It was imperative to develop recommendations that would prioritize the use of the expensive resource to the most vulnerable. The COID members met with a group of neonatologists, pulmonologists and CDC staff to review available data. This allowed the COID to modify the recommendations based on the best available evidence.
The approval of the HPV vaccine for males was also controversial. The COID was in communication with the CDC’s Advisory Committee on Immunization Practices and reviewed all new information concerning poor uptake of the HPV vaccine in females; new evidence on cancers, especially oral and anal, that occurred in both genders; and concerns that a female-only recommendation did not afford any protection for males who were men who have sex with men. The evidence suggested that expanding the vaccine eligibility to males increased costs. But the cost-effectiveness data suggested that given the new indications for both genders and the role of males in heterosexual transmission made it clear that it was the correct decision.
A third controversy was the decision over the meningococcal booster dose in adolescents. The meningococcal vaccine given at 11 to 12 years of age was already an expensive approach to a serious/life-threatening but relatively uncommon infection. However, it became clear that the dose at 11 to 12 years of age would not protect through the peak of meningococcal risk. Two options were available: 1) change the time of a single dose to 15 to 16 years of age; or 2) keep the initial dose at 11 to 12 years of age and add a booster at 15 to 16 years of age.
The second option was considered more appropriate because it prevented more cases and was more cost-effective — cost per quality-adjusted life year (QALY) was lower than a single dose at 15 to 16 years. Also, moving the single dose to 15 to 16 years would reduce protection to a group that had been previously protected (11- to 15-year-olds).
Hall: One area that was the most controversial involved the hepatitis B vaccination for infants at birth. Many people at that time felt that since hepatitis B was a disease of adolescents and adults immunizing infants at birth may not be the most effective strategy for preventing the later chronic sequelae.
Allowing immunization for healthy children and teenagers was also a controversial topic. Multiple new vaccines, including the conjugated ones, were becoming available, which brought the conundrum of how to best immunologically and feasibly incorporate them into the recommended vaccination schedule. Like this, many of the important issues of years ago have evolved in complexity and controversy, most notably the prevention of RSV, or have metamorphosed and re-emerged, like pertussis and measles.
How has the practice of pediatrics changed most over the years?
Hall: The vaccine programs have been very successful, indeed; so effective that parents no longer worry about their children contracting the past dreaded diseases, such as polio, but much more about the adverse effects of vaccines. Thus, the decision then becomes a personal one of risk to benefit, rather than a public health issue.
I do not know how to remedy this, but I hope that with our expanding use of online social media that the message of the beneficial effects of vaccines and their necessity for our sustained health will be better communicated to all, not only to parents, but also to children.
Brady: The explosion in new medical knowledge, as well as the increasing numbers of complex patients that are now surviving, many times into adulthood, has made it difficult to feel comfortable that anyone has adequate knowledge and skills to care for all of their patients’ needs.
The Internet has produced a more educated patient/family. That is extremely valuable, but it also provides access to misinformation. It has created greater expectations that are not always realistic. Medicine is now more than ever a “team” sport. Health care is no longer just a patient and their doctor. There are multiple providers (primary care physicians, nurses, subspecialists, therapists, pharmacists, etc) and numerous locations of care (doctor’s office, hospitals, urgent cares, emergency departments, minute clinics in grocery stores, school clinics, etc) and numerous payers (commercial insurance, government and self-pay). On top of this are more regulations. The interplay of all of these factors is making practicing medicine more complex. While none of these factors is inherently bad — and actually most are very good — they provide a challenge like never before.
What aspects of practicing pediatrics do you feel needs to change and has not?
Brady: The new movement to address what ails health care is continuous quality improvement (QI) and patient safety. We are just learning the science of QI. As we understand how to provide higher quality care with less variation supported by available evidence in the most cost-effective manner, we will be serving our patients and their families in the optimal manner.
Evidenced-based policies/guidelines that are produced by reputable groups are an initial component of providing evidence-based care. Unfortunately, there are still many areas of clinical care in pediatrics that do not have sufficient evidence to provide pediatricians with the best possible approach to care. We need to invest in obtaining the needed evidence.
Pickering: We need to educate parents and patients about the reasons why vaccine recommendations are made and convey information about the complex process that vaccines undergo before a recommendation is made to alleviate concerns among vaccine-hesitant parents. There is a great deal of research that supports vaccine recommendations, and we need to educate parents about those processes so there is a better understanding, wider acceptance and less concern about vaccines. – by Colleen Zacharyczuk
Michael T. Brady, MD, is in the department of pediatrics at The Ohio State University College of Medicine, and is also physician-in-chief at Nationwide Children’s Hospital, Columbus, Ohio. Caroline B. Hall, MD, is a professor of infectious diseases in the department of pediatrics and medicine at the University of Rochester Medical Center, Rochester, N.Y. Larry K. Pickering, MD, is senior adviser to the director of the National Center for Immunization and Respiratory Diseases of the CDC; editor of the Red Book; executive secretary of the ACIP; and professor of pediatrics at Emory University School of Medicine, Atlanta. Disclosures: Drs. Brady, Hall and Pickering report no relevant financial disclosures.